Prescription Drugs

CLINICAL PHARMACOLOGY Mechanism of Action The primary mode of action is thought to be through the osmotic effect of polyethylene glycol 3350 which causes water to be retained in the colon and produces a watery stool. Pharmacodynamics NuLYTELY induces as diarrhea which rapidly cleanses the bowel, usually within four hours. Pharmacokinetics The pharmacokinetics of PEG3350 following administration of NuLYTELY were not assessed. Available pharmacokinetic information for oral PEG3350 suggests that it is poorly absorbed.

NuLYTELY (polyethylene glycol 3350, sodium chloride, sodium bicarbonate and potassium chloride) for Oral Solution DESCRIPTION For oral solution: Each 4 liter (4L) NuLYTELY jug contains a white powder for reconstitution. NuLYTELY is a combination of polyethylene glycol 3350, an osmotic laxative, and electrolytes (sodium chloride, sodium bicarbonate and potassium chloride) for oral solution. Each 4 liter jug contains: polyethylene glycol 3350 420g, sodium bicarbonate 5.72 g, sodium chloride 11.2 g, potassium chloride 1.4g. The solution is clear and colorless when reconstituted to a final volume of 4 liters with water. Polyethylene Glycol 3350, NF Sodium Bicarbonate, USP The chemical name is NaHCO3. The average Molecular Weight is 84.01. The structural formula is: Sodium Chloride, USP The chemical name is NaCl. The average Molecular Weight: 58.44. The structural formula is: Na+Cl- Potassium Chloride, USP The chemical name is KCl. The average Molecular Weight: 74.55. The structural formula is: K-Cl

INDICATIONS NuLYTELY is indicated for bowel cleansing prior to colonoscopy in adults and pediatric patients aged 6 months or greater. DOSAGE AND ADMINISTRATION Dosage Overview NuLYTELY, supplied as a powder, must be reconstituted with water before its use; it is not for direct ingestion [see WARNINGS AND PRECAUTIONS]. The 4 liter reconstituted NuLYTELY solution contains: 420 grams of polyethylene glycol (PEG) 3350, 5.72 grams of sodium bicarbonate, 11.2 grams of sodium chloride, and 1.4 grams of potassium chloride. NuLYTELY may be used with or without one of the supplied flavor packs. Administration Instructions Prior to Dosage On the day prior to the colonoscopy, instruct patients to: Take only clear liquids, but avoid red and purple liquids. Patients may consume a light breakfast. If adding a NuLYTELY flavor pack, pour the contents of the 2 gram flavor powder (i.e., cherry, lemon-lime, orange or pineapple) into the container prior to reconstitution. No additional flavorings should be added. Discard unused flavor packs. The NuLYTELY flavor packs are for use only in combination with the contents of the accompanying 4 liter container. Early in the evening prior to colonoscopy, fill the supplied container containing the NuLYTELY powder (and if applicable, a flavor powder) with lukewarm water (to facilitate dissolution) to the 4 liter fill line. The solution is clear and colorless when reconstituted to a final volume of 4 liters. After capping the container, shake vigorously several times to ensure that the ingredients are dissolved. When reconstituted use within 48 hours. Dosage The following is the recommended dose of reconstituted NuLYTELY solution for adults and pediatric patients ≥ 6 months. Instruct patients they may consume water or clear liquids during the bowel preparation and after completion of the bowel preparation up until 2 hours before the time of the colonoscopy. The solution is more palatable if chilled prior to administration. Adults: Instruct patients to drink a total of up to 4 liters at a rate of 240 mL (8 oz.) every 10 minutes, until 4 liters are consumed or the rectal effluent is clear. Rapid drinking of each portion is preferred to drinking small amounts continuously. For NGT, rate is 2030 mL per minute (1.2 – 1.8 liters per hour). Pediatric Patients ≥ 6 Months: Pediatric patients should drink 25 mL/kg/hour until the stool is watery, clear, and free of solid matter. If pediatric patients are unable to drink the reconstituted NuLYTELY solution, the solution may be given by nasogastric (NGT). NGT administration is at the rate of 25 mL/kg/hour. The first bowel movements should occur approximately one hour after the start of NuLYTELY administration. Continue drinking until the watery stool is clear and free of solid matter. HOW SUPPLIED Dosage Forms And Strengths For oral solution: One 4 liter jug with powder for reconstitution with water. Each 4 liter jug contains: polyethylene glycol 3350 420 g, sodium bicarbonate 5.72 g, sodium chloride 11.2 g, potassium chloride 1.48 and flavoring ingredients 2g. When made up to 4 liters volume with water, the solution contains PEG-3350 31.3 mmol/L, sodium 65 mmol/L, chloride 53 mmol/L, bicarbonate 17 mmol/L and potassium 5 mmol/L. Storage And Handling In powdered form, for oral administration as a solution following reconstitution. NuLYTELY is available in a disposable jug in powdered form containing: NuLYTELY with Flavor Packs: polyethylene glycol 3350 420 g, sodium bicarbonate 5.72 g, sodium chloride 11.2 g, potassium chloride 1.48 g and flavoring ingredients 2.0 g (optional). When made up to 4 liters volume with water, the solution contains PEG-3350 31.3 mmol/L, sodium 65 mmol/L, chloride 53 mmol/L, bicarbonate 17 mmol/L and potassium 5 mmol/L. Each jug has an attached package containing 4 flavor packs (optional); one each 2.0g: Cherry, Lemon-Lime, Orange and Pineapple flavoring, in powdered form, for the addition of ONE pack by the pharmacist prior to dispensing. Lemon-Lime Flavor NuLYTELY: polyethylene glycol 3350 420 g, sodium bicarbonate 5.72 g, sodium chloride 11.2 g, potassium chloride 1.48 g and flavoring ingredients 2.0 g. When made up to 4 liters volume with water, the solution contains PEG-3350 31.3 mmol/L, sodium 65 mmol/L, chloride 53 mmol/L, bicarbonate 17 mmol/L and potassium 5 mmol/L. Storage Store at 25oC (77oF); excursions permitted to 15-30oC (59-86°F) [see USP Controlled Room Temperature]. When reconstituted, keep solution refrigerated. Use within 48 hours. Discard unused portion. Keep out of reach of children. NuLYTELY with Flavor Packs NDC 52268-400-01 Lemon-Lime Flavor NuLYTELY NDC 52268-302-01 Braintree Laboratories, Inc. Braintree, MA 02185, USA. Revised 9/2013

PATIENT INFORMATION NuLYTELY® (Noo-lite-ly) (PEG-3350, sodium chloride, sodium bicarbonate and potassium chloride) Oral Solution Read this Medication Guide before you start taking NuLYTELY. This information does not take the place of talking with your healthcare provider about your medical condition or your treatment. What is the most important information I should know about NuLYTELY? NuLYTELY and other osmotic bowel preparations can cause serious side effects, including: Serious loss of body fluid (dehydration) and changes in blood salts (electrolytes) in your blood. These changes can cause: abnormal heartbeats that can cause death seizures. This can happen even if you have never had a seizure. kidney problems Your chance of having fluid loss and changes in body salts with NuLYTELY is higher if you: have heart problems have kidney problems take water pills or non-steroidal anti-inflammatory drugs (NSAIDS) Tell your healthcare provider right away if you have any of these symptoms of a loss of too much body fluid (dehydration) while taking NuLYTELY: vomiting that prevents you from keeping down the solution dizziness urinating less often than normal headache See Section “What are the possible side effects of NuLYTELY” for more information about side effects. What is NuLYTELY? NuLYTELY is a prescription medicine used by adults to clean the colon before a colonoscopy. NuLYTELY cleans your colon by causing you to have diarrhea. Cleaning your colon helps your healthcare provider see the inside of your colon more clearly during your colonoscopy. NuLYTELY is safe and effective for use in pediatric patients aged 6 months and older. Who should not take NuLYTELY? Do not take NuLYTELY if your heathcare provider has told you that you have: a blockage in your bowel (obstruction) an opening in the wall of your stomach or intestine (bowel perforation) problems with food and fluid emptying from your stomach (gastric retention) a very dilated intestine (bowel) an allergy to any of the ingredients in NuLYTELY. See the end of this leaflet for a complete list of ingredients in NuLYTELY. What should I tell my healthcare provider before taking NuLYTELY? Before you take NuLYTELY, tell your healthcare provider if you: have heart problems have stomach or bowel problems have ulcerative colitis have problems with swallowing or gastric reflux have a history of seizures are withdrawing from drinking alcohol have a low blood salt (sodium) level have kidney problems any other medical conditions are pregnant. It is not known if NuLYTELY will harm your unborn baby. Talk to your doctor if you are pregnant or plan to become pregnant. are breastfeeding or plan to breastfeed. It is not known if NuLYTELY passes into your breast milk. You and your healthcare provider should decide if you will take NuLYTELY while breastfeeding. Tell your healthcare provider about all the medicines you take, including prescription and non-prescription medicines, vitamins, and herbal supplements. NuLYTELY may affect how other medicines work. Medicines taken by mouth may not be absorbed properly when taken within 1 hour before the start of NuLYTELY. Especially tell your healthcare provider if you take: medicines for blood pressure or heart problems medicines for kidney problems medicines for seizures water pills (diuretics) non-steroidal anti-inflammatory medicines (NSAID) pain medicines laxatives Ask your healthcare provider or pharmacist for a list of these medicines if you are not sure if you are taking any of the medicines listed above. Know the medicines you take. Keep a list of them to show your healthcare provider and pharmacist when you get a new medicine. How should I take NuLYTELY? You must read, understand, and follow these instructions to take NuLYTELY the right way. Take NuLYTELY exactly as your healthcare provider tells you to take it. Drink 240 mL (8 oz.) every 10 minutes. Rapid drinking of each portion is better that drinking small amounts. The first bowel movement should occur approximately one hour after you start drinking the solution. You may experience some abdominal bloating and distention before the bowels start to move. If severe discomfort or distention occur, stop drinking temporarily or drink each portion at longer intervals until the discomfort goes away. Continue drinking until the watery stool is clear and free of solid matter. This usually requires 3 liters and it is best to drink all of the solution. Do not take undissolved NuLYTELY powder that has not been mixed with water (diluted), it may increase your risk of nausea, vomiting and fluid loss (dehydration). Each jug of NuLYTELY must be reconstituted with water (diluted) to 4 liters total volume before drinking. Do not take other laxatives while taking NuLYTELY. Do not eat solid foods on the day before your colonoscopy and until after your colonoscopy. Drink only clear liquids: the day before your colonoscopy while taking NuLYTELY after taking NuLYTELY until 2 hours before your colonoscopy What are the possible side effects of NuLYTELY? NuLYTELY can cause serious side effects, including: See Section “What is the most important information I should know about NuLYTELY?” changes in certain blood tests. Your healthcare provider may do blood tests after you take NuLYTELY to check your blood for changes. Tell your healthcare provider if you have any symptoms of too much fluid loss, including: vomiting nausea bloating dizziness stomach (abdominal) cramping headache urinate less than usual trouble drinking clear liquid heart problems. NuLYTELY may cause irregular heartbeats. seizures ulcers of the bowel or bowel problems (ischemic colitis). Tell your healthcare provider right away if you have severe stomach-area (abdomen) pain or rectal bleeding. The most common side effects of NuLYTELY include: nausea stomach (abdominal) fullness bloating stomach (abdominal) cramps vomiting anal irritation Tell your healthcare provider if you have any side effect that bothers you or that does not go away. These are not all the possible side effects of NuLYTELY. For more information, ask your healthcare provider or pharmacist. Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088. How should I store NuLYTELY? Store NuLYTELY at room temperature, between 59°F to 86°F (15°C to 30°C). Keep NuLYTELY and all medicines out of the reach of children. General information about the safe and effective use of NuLYTELY. Medicines are sometimes prescribed for purposes other than those listed in a Medication Guide. Do not use NuLYTELY for a condition for which it was not prescribed. Do not give NuLYTELY to other people, even if they are going to have the same procedure you are. It may harm them. This Medication Guide summarizes important information about NuLYTELY. If you would like more information, talk with your healthcare provider. You can ask your pharmacist or healthcare provider for information that is written for healthcare professionals. For more information, go to www.braintreelabs.com or call 1-800-874-6756. What are the ingredients in NuLYTELY? Active ingredients: polyethylene glycol 3350, sodium sulfate, sodium bicarbonate, sodium chloride, and potassium chloride. Inactive ingredients: cherry flavoring, lemon-lime flavoring, orange flavoring, pineapple flavoring (flavor packs only)

SIDE EFFECTS The following adverse reactions have been identified during post-approval use of NuLYTELY. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure. Nausea, abdominal fullness and bloating are the most common adverse reactions (occurred in up to 50% of patients) to administration of NuLYTELY. Abdominal cramps, vomiting and anal irritation occur less frequently. These adverse reactions are transient and usually subside rapidly. Isolated cases of urticaria, rhinorrhea, dermatitis and (rarely) anaphylactic reaction have been reported which may represent allergic reactions. Published literature contains isolated reports of serious adverse reactions following the administration of PEG-electrolyte solution products in patients over 60 years of age. These adverse events include upper GI bleeding from Mallory-Weiss Tear, esophageal perforation, asystole, sudden dyspnea with pulmonary edema, and “butterfly-like” infiltrates on chest X-ray after vomiting and aspirating PEG. DRUG INTERACTIONS Drugs that May Lead to Fluid and Electrolyte Abnormalities Use caution when prescribing NuLYTELY for patients who are using medications that increase the risk for fluid and electrolyte disturbances or may increase the risk of adverse events of seizure, arrhythmias, and prolonged QT in the setting of fluid and electrolyte abnormalities. Consider additional patient evaluations as appropriate [see WARNINGS AND PRECAUTIONS] in patients taking these concomitant medications. Potential for Altered Drug Absorption Oral medication administered within one hour of the start of administration of NuLYTELY may be flushed from the gastrointestinal tract and the medication may not be absorbed properly. Stimulant Laxatives Concurrent use of stimulant laxatives and NuLYTELY may increase the risk of mucosal ulceration or ischemic colitis. Avoid use of stimulant laxatives (e.g., bisacodyl, sodium picosulfate) while taking NuLYTELY.

WARNINGS Included as part of the PRECAUTIONS section. PRECAUTIONS Serious Fluid and Serum Chemistry Abnormalities Advise patients to hydrate adequately before, during, and after the use of NuLYTELY. Use caution in patients with congestive heart failure when replacing fluids. If a patient develops significant vomiting or signs of dehydration including signs of orthostatic hypotension after taking NuLYTELY, consider performing post-colonoscopy lab tests (electrolytes, creatinine, and BUN) and treat accordingly. Fluid and electrolyte disturbances can lead to serious adverse events including cardiac arrhythmias, seizures and renal impairment. Fluid and electrolyte abnormalities should be corrected before treatment with NuLYTELY. In addition, use caution when prescribing NuLYTELY for patients who have conditions, or who are using medications, that increase the risk for fluid and electrolyte disturbances or may increase the risk of adverse events of seizure, arrhythmias, and renal impairment [see DRUG INTERACTIONS] Cardiac Arrhythmias There have been rare reports of serious arrhythmias associated with the use of ionic osmotic laxative products for bowel preparation. Use caution when prescribing NuLYTELY for patients at increased risk of arrhythmias (e.g., patients with a history of prolonged QT, uncontrolled arrhythmias, recent myocardial infarction, unstable angina, congestive heart failure, or cardiomyopathy). Pre-dose and post-colonoscopy ECGs should be considered in patients at increased risk of serious cardiac arrhythmias. Seizures There have been reports of generalized tonic-clonic seizures and/or loss of consciousness associated with use of bowel preparation products in patients with no prior history of seizures. The seizure cases were associated with electrolyte abnormalities (e.g., hyponatremia, hypokalemia, hypocalcemia, and hypomagnesemia) and low serum osmolality. The neurologic abnormalities resolved with correction of fluid and electrolyte abnormalities. Use caution when prescribing NuLYTELY for patients with a history of seizures and in patients at increased risk of seizure, such as patients taking medications that lower the seizure threshold (e.g., tricyclic antidepressants), patients withdrawing from alcohol or benzodiazepines, or patients with known or suspected hyponatremia. Renal Impairment Use caution when prescribing NuLYTELY for patients with impaired renal function or patients taking concomitant medications that may affect renal function (such as diuretics, angiotensin converting enzyme inhibitors, angiotensin receptor blockers, or non-steroidal anti-inflammatory drugs). Advise these patients of the importance of adequate hydration, and consider performing baseline and post-colonoscopy laboratory tests (electrolytes, creatinine, and BUN) in these patients. Colonic Mucosal Ulcerations and Ischemic Colitis Administration of osmotic laxative products may produce colonic mucosal aphthous ulcerations, and there have been reports of more serious cases of ischemic colitis requiring hospitalization. Concurrent use of stimulant laxatives and NuLYTELY may increase this risk. The potential for mucosal ulcerations resulting from the bowel preparation should be considered when interpreting colonoscopy findings in patients with known or suspect inflammatory bowel disease (IBD). Use in Patients with Significant Gastrointestinal Disease If gastrointestinal obstruction or perforation is suspected, perform appropriate diagnostic studies to rule out these conditions before administering NuLYTELY. If a patient experiences severe bloating, distention or abdominal pain, administration should be slowed or temporarily discontinued until the symptoms abate. If gastrointestinal obstruction or perforation is suspected, appropriate studies should be performed to rule out these conditions before administration of NuLYTELY. Use with caution in patients with severe active ulcerative colitis. Aspiration Use with caution in patients with impaired gag reflex, unconscious, or semiconscious patients, and patients prone to regurgitation or aspiration. Such patients should be observed during administration of NuLYTELY, especially if it administered via nasogastric tube. Not for Direct Ingestion The contents of each jug must be diluted with water to a final volume of 4 liters (4 L) and ingestion of additional water is important to patient tolerance. Direct ingestion of the undissolved powder may increase the risk of nausea, vomiting, dehydration, and electrolyte disturbances. Patient Counseling Information See FDA-Approved Patient Labeling (Medication Guide). Instruct patients: To let you know if they have trouble swallowing or are prone to regurgitation or aspiration. Not to take other laxatives while they are taking NuLYTELY. To consume water or clear liquids during the bowel preparation and after completion of the bowel preparation up until 2 hours before the time of the colonoscopy. That if they experience severe bloating, distention or abdominal pain, the administration of the solution should be slowed or temporarily discontinued until the symptoms abate. Advise patients to report these events to their health care provider. That if they have hives, rashes, or any allergic reaction, they should discontinue the medication and contact their health care provider. Medication should be discontinued until they speak to their physician. To contact their healthcare provider if they develop signs and symptoms of dehydration. [see WARNINGS AND PRECAUTIONS]. That oral medication administered within one hour of the start of administration of NuLYTELY solution may be flushed from the GI tract and the medication may not be absorbed completely. Nonclinical Toxicology Carcinogenesis, Mutagenesis, Impairment of Fertility Long term studies in animals have not been performed to evaluate carcinogenic potential of NuLYTELY. Studies to evaluate the possible impairment of fertility or mutagenic potential of NuLYTELY have not been performed. Use In Specific Populations Pregnancy Pregnancy Category C Animal reproduction studies have not been conducted with NuLYTELY. It is also not known whether NuLYTELY can cause fetal harm when administered to a pregnant woman or can affect reproductive capacity. NuLYTELY should be given to a pregnant woman only if clearly needed. Nursing Mothers It is not known whether this drug is excreted in human milk. Because many drugs are excreted in human milk, caution should be exercised when NuLYTELY is administered to a nursing woman. Pediatric Use Safety and effectiveness of NuLYTELY in pediatric patients aged 6 months and older is supported by evidence from adequate and well-controlled clinical trials of NuLYTELY in adults with additional safety and efficacy data from published studies of similar formulations. Use of NuLYTELY in children younger than 2 years of age should be carefully monitored for occurrence of possible hypoglycemia, as this solution has no caloric substrate. Dehydration has been reported in one child and hypokalemia has been reported in 3 children. Geriatric Use Clinical studies of NuLYTELY did not include sufficient numbers of subjects aged 65 and over to determine whether they respond differently from younger subjects. Other reported clinical experience has not identified differences in responses between the elderly and younger patients.